Hernia (2008) 12:421–423 DOI 10.1007/s10029-007-0308-2

C A S E RE P O RT

A perforated diverticulum of the sigmoid colon found within a strangulated inguinal hernia M. L. A. Tufnell · C. Abraham-Igwe

Received: 7 August 2007 / Accepted: 26 October 2007 / Published online: 15 November 2007 © Springer-Verlag 2007

Abstract We present a rare occurrence of a perforated diverticulum of the sigmoid colon found within the contents of a strangulated left inguinal hernia in a 75-year-old man. The hernia was repaired using the Bassini technique. An end colostomy was established after resection of the diseased section of the sigmoid. We review the relevant literature and discuss the choice of repair techniques in such situations. Keywords Inguinal hernia · Diverticulum · Sigmoid colon

Introduction Inguinal herniae have rarely been reported to have a wide variety of unusual sac contents, including the urinary bladder [1], fallopian tube and ovaries [2], Meckel’s diverticulum [3] and appendix [4]. Though most surgeons never encounter any of these in their working life, many are conversant with eponymous terms like Littre’s hernia—the presence of a Meckel’s diverticulum within an inguinal hernia. The Wnding of large bowel diverticulum in an inguinal hernia is very rare and we discovered only a limited number of cases in the literature.

M. L. A. Tufnell · C. Abraham-Igwe The Royal Surrey County Hospital NHS Trust, Egerton Road, Guildford GU2 7XX, England, UK M. L. A. Tufnell (&) London, UK e-mail: [email protected]

Case report A 75-year-old man presented to the surgical assessment unit with a tender, large left inguino-scrotal swelling. He had a long history of large bilateral inguinal herniae, with repair of the right side 5 weeks previously at another hospital. The repair of the left side had been planned for a later date. We are not exactly sure why this was not done at the same sitting, but we know the patient’s other medical problems included severe secondary hypertension from renal hypoplasia, non-insulin dependent diabetes mellitus and ischaemic heart disease. The presenting swelling, though irreducible for a long time, had gradually increased in size over the previous 2 weeks, with progressive extension into the scrotum. It had now become very painful in the previous 24–48 h. The patient had not opened his bowel in 24 h. On examination, the patient was in much discomfort, had a temperature of 37.6°C and looked slightly dehydrated. The abdomen was slightly distended and soft but there was tenderness, which was more marked in the left iliac fossa. There was a tender, incarcerated left inguinoscrotal hernia with very inXamed overlying skin. The inXammatory markers were raised, with a white cell count of 18,000 cells/mm3 and a CRP of 248 mg/l. There was some renal dysfunction, with a urea of 11.0 mmol/l and a creatinine of 182
mol/l. The abdominal X-ray did not show any features of bowel obstruction. A clinical diagnosis of strangulated inguinal hernia was made and the patient prepared for urgent surgery. On exploration of the left groin, a strangulated indirect inguinal hernia was conWrmed and the sac was found to contain non-viable large bowel wall with some faeces observed in the wound. A laparotomy was done through a midline incision and this revealed the sac content to be a

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non-viable large diverticulum of the sigmoid. This had perforated at the base, with some faecal contamination of the pelvic cavity. Limited resection of the sigmoid was performed and an end colostomy established (Hartmann’s procedure). The pelvic cavity was washed out thoroughly and a large pelvic drain inserted. The hernia was repaired primarily using the Bassini technique. Post-operatively, the patient was severely hypertensive, requiring infusions of labetalol and GTN for control. He was also septic and slow to initiate bowel movement. He went on to develop an infection of his laparotomy wound, leading to a partial wound breakdown. This required a vacuum-assisted dressing because of the high exudate of the wound. The patient made a slow but gradual recovery and was eventually Wt to be discharged home 24 days after surgery.

Discussion There is no doubt from the literature that any diverticulum of large or small bowel could Wnd its way into an inguinal hernial sac. These include the appendix and Meckel’s diverticulum. An appendix is estimated to be found in about 1% of inguinal hernia sacs. An inXamed appendix (a true Amyand’s hernia) is found in about 0.1% of cases [5, 6]. This condition was named after Claudius Amyand, who reported the occurrence of a perforated appendicitis in an inguinal hernia in 1735 and indeed performed the Wrst recorded successful appendicectomy in the same patient [4]. The presence of other large bowel diverticulae in an inguinal hernia, as reported in the literature, is much rarer. Analogous to the Amyand's hernia would be the Wnding of an inXamed diverticulum of the colon within an inguinal hernial sac. This is very rare and only two reported cases were found, one being a sigmoid diverticulum [7] and the other from the transverse colon [8]. More commonly reported is the tracking of a diverticular abscess through the inguinal ring to simulate the clinical picture of an incarcerated hernia. The case reported by Bunting et al. [9] certainly sounded like one of these, as the diverticulum was not found within the hernial sac at surgery. In our patient, a solitary large diverticulum had herniated into the hernia sac. At surgery this was found to be strangulated with perforation at the base, which had been the site of the constriction. The rest of the sigmoid, though full of other small diverticulae, looked relatively healthy. The management of this situation in an emergency was by a Hartmann’s procedure, especially considering the presence of sepsis and other co-morbidities. In the absence of any peritoneal contamination, resection and primary anastomosis would have been considered if the expertise was available. As only the diverticulum was presenting in the sac,

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the assessment of the rest of the bowel as well as the extent of the diseased segment would have been diYcult without the midline incision. The hernia was repaired primarily using the Bassini technique. This choice was made based on the surgeon’s familiarity with this procedure. The principal method of hernia repair in the UK is the Lichtenstein repair, with which most Specialist Registrars (SpR) would be familiar. However, many SpRs in the UK would have become increasingly unfamiliar with non-mesh methods of hernia repair as opportunities to do these electively have almost become none existent. As most emergencies are still handled by SpRs, this creates a problem in a case like the one we have described when it is clearly inappropriate to repair the hernia with a mesh. It would appear that targeted training to ensure the acquiring of skills for non-mesh repair of inguinal herniae is still essential. The method to be taught will depend on the expertise widely available. The Shouldice repair is reported to show a recurrence rate of less than 1% at specialist centres such as that in Ontario, Canada [10]. However, these are not reproduced by other non-specialist centers [11] that have less experience with the technique. In a situation like we had, the Bassini technique is perfectly acceptable. The use of mesh may not be absolutely contraindicated in a strangulated hernia if there is minimal contamination and broad spectrum antibiotics are used during and after the operation for several days [12, 13].

Conclusion There are a variety of possible diagnoses in patients presenting with an incarcerated inguinal hernia, which are in the majority of cases diYcult to establish before surgery. A perforated diverticulum of the sigmoid colon presenting within an incarcerated inguinal hernia is a very rare occurrence. Surgical management of this condition may vary depending on the presence of intraperitoneal contamination, along with the experience and personal judgement of the surgeon. As these patients are likely to be elderly, the safest and quickest means of management are required in an emergency. The Hartmann’s procedure still represents the best way to manage these situations. Non-mesh methods of hernia repair are required when the hernia site is contaminated, and the skills for this may be fast disappearing among trainees in the UK.

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